A Survey of Point of Use Household Water Treatmen

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Georgia State University Digital Archive @ GSU

Public Health eses Institute of Public Health

1-6-2012

A Survey of Point of Use Household WaterTreatment Options for Rural South IndiaKendralyn G. Je [email protected]

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Recommended Citation Je reys, Kendralyn G., "A Survey of Point of Use Household Water Treatment Options for Rural South India" (2012). Public HealthTeses. Paper 190.
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High quality water is more than the dream of the conservationists, more than a politicalslogan; high quality water . . . is essential to health, recreation, and economic growth.

--Edmund S. Muskie, U.S. Senator, speech, March 1, 1966

-.!/012)!-0.Water is the very foundation of life, and few would argue that access to clean consumablewater is as inalienable a right as breathing clean air. However, for billions of peopleacross the globe, access to safe drinking water is limited and sometimes almostimpossible to find. The World Health Organization (WHO) defines safe drinking wateras, water that does not represent any significant risk to health over a lifetime ofconsumption, including different sensitivities that may occur between life stages (WorldHealth Organization, 2008, p. 1). Lack of safe water creates an enormous burden in theform of waterborne illnesses such as diarrheal disease, cholera, typhoid, and Guineaworm disease. Diarrheal disease itself is a leading cause of mortality and morbidity

among children under the age of five and, overall, was the third leading cause of death inlow-income countries in 2004 (World Health Organization, 2009).

In the year 2000, the United Nations (UN) set eight Millennium Development Goals(MDGs), one of which is to halve the proportion of the worlds population that does nothave access to improved water sources (United Nations, 2000). In the eleven yearssince that goal was set, considerable progress has

been made, particularly in China and India, whichtogether contain approximately a third of the worlds

population. A 2010 WHO/UNICEF JointCommission Report notes that 88% of the 1.2 billion

people in India now have access to improved watersources, an increase from 72% in 1990. However, the report notes that simply havingimproved water sources does not necessarily mean that the water is safe to drink(WHO/UNICEF, 2010). This report describes the situation that millions of people inIndia find themselves in today.

While the ultimate goal is to have treated water piped into every household, a realisticassessment of the infrastructure of many developing countries suggests that this goal isexpensive and years away from being achieved. In the interim is it possible for people inthese areas to have access to clean drinking water? Fortunately, the answer is aresounding, yes! Treating water at a household level is one way to provide cleandrinking water for populations in areas where the infrastructure is lacking. Householdwater treatment (HWT) has been in existence for several millennia and takes manydifferent forms depending on the localeand resources available. When acontinuous supply of electricity isavailable, the point of use (POU)household water treatment (HWT) technologies are numerous; some

Point of Use Household Water Treatment (POUHWT): treating drinking water at the household levelto improve its microbiological purity before the wateris used. POU treatment can provide clean water for

people without access to clean, municipally treatedwater, a common scenario in the developing world.

Sobsey et al. 2008

Improved water sources: water from protected tube or bore wells, dug wells, public taps and collected rainwater.

WHO/UNICEF JMP Report 2010


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examples of such household level systems are ones that purify the water by reverseosmosis (e.g., Kent Osmosis System) or ones that combine several treatment processeslike boiling, ultraviolet treatment and sediment filtration (e.g., Aqua Guard PurificationSystem) (Jain, 2009). However, rural, low-income people in developing countries do notoften have continuous access to electricity, and they are often the ones at greatest risk of

having an unsafe water supply; therefore, for this report we will focus on examining onlyfield-tested, non-electric, low-cost point of use technologies for household watertreatment.

9LMN',%The objectives of this report are:

1. To provide the reader with a basic understanding of the household water situationin southern India, including socio-cultural practices that may impact a POUintervention program.

2. To provide the reader with a basic overview of non-electric POU technologiesthat could potentially be used in rural South India .

3. To discuss the different factors to considerwhen determining which POU technologywill work best in a community, using a casestudy of a village in Andhra Pradesh toillustrate.

4. To provide the reader with a compendium of helpful resources related tointroducing and implementing a new POU program in rural South India.

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The chief pathogens associated with diarrheal disease are mainly transmitted whenhumans ingest food or water that has been contaminated by fecal matter. It is estimated

that 94% of diarrheal disease can be attributed to environmental factors, such as a lack of proper sanitation and hygiene and unsafe drinkingwater (Prss-Ustn & Corvaln, 2007). While anyintervention that aims to greatly reduce diarrhealdisease in India should also include a focus onsanitation and hygiene practices, multiple reviews andstudies conducted in the last two decades have suggested that improving drinking waterat the household level (also referred to as point of use, or POU treatment) can reducediarrheal disease rates in a community by as much as 30-40% (Clasen, 2009; T. F.Clasen, Brown, Collin, Suntura, & Cairncross, 2004; Thomas Clasen, Schmidt, Rabie,Roberts, & Cairncross, 2007; Lorna Fewtrell et al., 2005). There are multiple POUtechnologies in existence, but only a few have been extensively field-tested and workwithout electricity; these particular POU systems will be the focus of this report. ThePOU systems examined here are: chlorine treatment, chlorine-flocculant sachets, biosandfilters, ceramic filters, and solar disinfection treatment. Boiling is also discussed since itis one of the oldest and most well-known water treatment options in the developingworld.

Fecal contamination : measured by performing a lab analysis that tests forthe presence of E. coli in the water.


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!O% 9OR,ST"$ 7*USM'*Q%*+For centuries Indias people have devised creative solutions to adapt to Indias highlyseasonal pattern of rainfall which, in some areas, sees 50% of the annual precipitation

falling in just 15 days (Briscoe, 2005). Indias monsoon or rainy season is typicallyfrom June to September. Especially for southern India, those four months provide

precious rainfall that fills tanks, rivers and reservoirs with water which must last until thenext monsoon season (Wolpert, 2009). This pattern of rainfall has compelled the native

population to devise a variety of ways to harvest and store water.

In a 2005 World Bank report about the water situation in India, author John Briscoedescribes some of the major issues threatening India today: a growing population, limitedwater supplies, inadequate public infrastructure, the growth of urban areas, and thecontinued major pollution of some of Indias rivers. The same water issues faced in othercountries might lead to social and civil unrest; however, as a whole, the Indian people

have developed coping strategies on an individual level to deal with an unpredictable andoften polluted water supply. Some of the most common coping strategies used by the

population are storing water in containers, installing household level water treatmentsystems, purchasing water from private vendors, and digging bore wells to accessgroundwater (Briscoe, 2005). A bore well (also referred to as a tube well) is a long metaltube that is drilled into the ground until it reaches an aquifer ; the water is then pumpedup by hand or by a motorized pump. There are an estimated 21 million bore wells inIndia; this has led to a depletion of the water table sincethe groundwater is being used at a greater rate than it can

be replenished (Climate Institute, 2010). It is estimatedthat 80% of the domestic water supply in India is from

groundwater (Briscoe, 2005).9'$S+ST, "*P 5"+%MThe Indian government began focusing on improving water and sanitation in 1972through the national Accelerated Rural Water Supply Program (ARWSP). This programassists the states and territories in increasing drinking water supplies in rural areas. TheDepartment of Drinking Water Supply (DDWS) was formed in 1999, and placed underthe Ministry of Rural Development in order to emphasize the need for focusing on ruralwater and sanitation development. DDWS is one of the main governmental institutionson a national scale that supports the states and territoriesin improving sanitation and clean water supplies. In

2007, the national government identified the mainobstacles they face in developing rural water supplies: alack of available water, poor water quality, the large costof installing, operating and maintaining a water supply, and whether to take a national orlocal approach to rural water development (Planning Commission, Government of India,2007).

Aquifer: an underground layer ofrock that yields ground water forsprings or wells. -- www.lexic.us

The Ministry of Rural Development

oversees the Department of DrinkingWater Supply on a national level.


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However, the increased focus of the national government on improving rural water andsanitation does not mean it is always effectively implemented on a local level. Thegovernment is supposed to treat all government-owned water storage tanks with adisinfectant, usually a bleaching powder (hypochlorite). However, it is not always certainif the water in the government tanks is being treated. Even in more urban areas where the

water supply is supposed to be safer because it is presumed to be treated by both filtrationand chlorination, there is no guarantee that these practices are actually being performed by the government on a regular basis (Brick et al., 2004). The primary source of a 1994cholera outbreak in Vellore, Tamil Nadu, was water from a government-maintained watersource that officials had stopped chlorinating due to financial constraints (Ramakrishna,Kang, Rajan, Mathan, & Mathan, 1996). More recently, in a 2004 study of water storage

practices in Vellore, all of the water collected from the municipal water taps in the villagewere contaminated with E. coli , which indicates fecal contamination. The governmentofficials would not respond to researchers when asked about their chlorination practicesand records (Brick et al., 2004).

The WHO/UNICEF Joint Monitoring Programme (JMP) for Water Supply and Sanitation produces a report that is designed to provide a macro-view of a countrys sanitation andwater situation by measuring the level of access to improved water sources throughoutthe country based on several non-governmental national level surveys. In the latest report,JMP states that 84% of the population of India has access to improved water supplies,with 94% coverage in urban areas and 80% in rural; both these numbers are lower thanthe previous 2006 estimates (Joint Monitoring Programme for Water Supply andSanitation, 2010).

A 2010 study conducted a statistical analysis of the safe water coverage in the state ofMadhya Pradesh and also took various water quality samples around the state; the

researchers then compared their findings to both the JMP 2007 report and the nationalgovernments figures. The researchers found that both the JMP and the Indiangovernments definition of improved water sources do not take into account the quality ofthe water. In some areas of Madhya Pradesh, the JMP numbers estimating safe watercoverage would be reduced by 40% if the microbiological quality of the water were takeninto account (Godfrey, Labhasetwar, Wate, & Pimpalkar, 2010). As these studiesindicate, until the government-supplied and other improved water sources becomemore microbiologically reliable, household water treatment systems may be the bestsolution for providing safe drinking water to the general population in the interim.

)'QQ'* 5"+%M ;'LMT%, S* /LM"$ -*PS"The most common source of water in southern India is groundwater accessed by deep

bore wells; the water from the bore well is typically pumped into overhead governmentwater tanks or accessed by stand-alone taps or pumps which are fed water from the borewell through subterranean pipes. Open wells are also common.

Even if the water from the bore well is microbiologically pure, it may becomecontaminated while being delivered to the surface, as shown by a study in a village inTamil Nadu. The water from the public taps connected to the main government watertank all showed high levels of thermotolerant coliforms, which indicate fecal


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contamination; because the high coliform count was consistently found in further tests,the government tank itself was tested and was also found to have notably high coliformcounts (despite the fact that it was scheduled to be chlorinated once a month). The waterfrom the government water tank came from a deep bore well which accessedgroundwater far below the surface. While the researchers were unable to test the bore

well water source directly, they theorized that the water may have been contaminated by passing through cracked pipes on the way to the surface (Firth et al., 2010). Watercontamination from cracked pipes is certainly feasible if the ground surrounding the pipesis tainted with fecal contamination and becomes saturated with water, a commonoccurrence during monsoon season. For example, in Vellore, Tamil Nadu, the mainsource of water is surface and groundwater, with the groundwater water coming from

bore wells that are located in a dry riverbed. Since the riverbed is dry, it is used foranimal waste disposal and human defecation year-round. During the heavy rains ofmonsoon season, water mixed with human and animal waste supersaturates the ground; ifthis feces-polluted water reaches the depth of the groundwater, it can lead tocontamination of the bore well at its source (Brick et al., 2004).

5"+%M ;+'M"V% 9M"T+ST%, S* ;'L+O%M* -*PS"In many developing countries, families often store water in their homes. This practice isdue in part to a lack of piped water (thus they must collect the water manually), or, evenwhen water is piped into the house, it may not be available at all times. In India, theintermittent availability of water is a common problem in both urban and rural areas,mainly due to seasonal shifts affecting water sources; thus, many households adopt the

practice of storing water in containers inside their homes (Brick et al., 2004).

The literature has shown that water storage is associated with increased fecalcontamination of the water even if the water is microbiologically pure when it isoriginally collected. A meta-analysis looking at studies that measured levels of bacterialcontamination at both the water source and stored water in households found that half ofthe studies analyzed indicated significant contamination of the water after it was obtainedfrom the source. Thus the authors concluded that contamination is a significant risk in thetime between collecting water from the source and point of use (Wright, Gundry, &Conroy, 2004).

There are a variety of factors that increase the chance of contaminating the water aftercollecting it from the source. Factors such as the width of the opening of the container,the material the container is made of, and the manner in which individuals retrieve thewater all impact the risk of polluting the water. In a study of water handling anddefecation practices in rural India, researchers found that 100% of the study participantsreported storing water in wide-mouth containers along with using cups to retrieve waterfrom the containers. This type of practice increases the risk of polluting the water withunclean hands (Banda et al., 2007). People cannot put their hands into a container with anarrow opening, which lowers the risk of fecal contamination; therefore, a hallmark of asafe water storage system is having containers with narrow openings.

In a 2004 study of 37 low-income urban households in Vellore, Tamil Nadu, researchersfound that all the surveyed households stored water at home. These water storage


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containers all had wide-mouth openings and were made of a variety of materials:aluminum, brass, plastic, steel, and earthenware. The study tested the water at its source(a municipal tap) and then tested the stored water 1 to 7 days after the original collectiondate.

Significantly, the researchers found that the stored water was more contaminated than thewater tested at the source, which suggests that contamination occurred at the householdlevel. Also, the study found that there were significantly lower levels of fecalcontamination in brass containers compared to other containers, particularly earthenwareones (Brick et al., 2004). A later study on brass containers in India confirmed that fecalmicroorganisms in the water are reduced significantly when stored in brass containers for12-48 hours, perhaps due to the biocidal properties of some heavy metals (Tandon,Chhibber, & Reed, 2005). When considering which type of POU option may be best for acommunity, it is important to assess the communitys current water storage practices and,if they have unsafe storage containers and practices, explore vible options to obtain safewater storage containers.

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fields under cultivation. Consequently, during times of heavy rain in the monsoon season,the village could potentially be flooded with water heavily contaminated with fecalmatter from the fields (Gopal et al., 2009).

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For any health intervention to be effective, it must consider local beliefs about the illnessit aims to reduce or treat. The local villagers may not view an illness in the same way asan outsider coming from a Western, biomedical perspective; thus, it is important to learnhow the local people define illnesses and their causes. This principle is particularly truein India when dealing with water, sanitation, and hygiene practices. Using the followingquestions to elicit a persons explanatory model of illness can be very helpful:

1. What do you call your illness? What name does it have?2. What do you think has caused the illness?3. Why and when did it start?4. What do you think the illness does? How does it work?5. How severe is it? Will it have a short or long course?6. What kind of treatment do you think you should receive? What are the most

important results you hope to receive from the treatment?7. What are the chief problems the illness has caused?8. What do you fear most about the illness? (Kleinman, 1988)

In different cultures, people may not consider diarrhea a disease. For those that doidentify diarrhea as an illness, the reasons they identify why people get diarrhea may varysubstantially. In one study in India, only 12.4% of study participants identified water as a

potential source of diarrheathe other participants identified food, heat, mosquito bites,or accidentally ingesting hair or mud as the causes of diarrhea. Approximately 15% of thestudy participants said they simply didnt know what caused diarrhea (Banda et al.,2007). Similarly, a POU intervention in neighboring Nepal found that over 40% of study

participants did not identify unclean water as a potential source of diarrhea (Rainey &Harding, 2005). These studies illustrate why it is essential to explore the populations

perspective about the targeted illness, both in order to have a culturally sensitiveintervention and to identify potential areas for health education early in the program.

)L$+LM"$ K%$S%(, "#'L+ 5"+%MAnother important factor to consider is local beliefs about water. In India, water holds aspecial place in the hearts of many of its people, especially Hindus. The Ganges River isconsidered sacred in Hindu culture and Mother Ganga is worshiped as a goddess.Devout Hindus visit the Ganges to ritually bathe, pray and, eventually, have their ashesspread in the river (Wolpert, 2009). Water is associated with purification in Hinduculture, not pollution or contamination; consequently, it may be more difficult for Hindusto view water as a source of disease. During a household water treatment intervention in

Nepal, researchers encountered resistance from Hindu participants in believing that thewater was polluted and needed to be treated at all, a view that the authors attributed tocoming from the strong association between water and purity in Hinduism (Rainey &Harding, 2005).


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Several studies in India and neighboring countries have also found that participants tendto view water as clean or unclean based on aesthetic qualities such as smell, taste, andcolor, with taste being a significant factor (Banda et al., 2007; Firth et al., 2010; Rainey& Harding, 2005). Furthermore, Indian study participants have indicated that there areappropriate times to use boiled water (for babies or during an illness), but they did not see

a need to treat water beyond these two occasions (Banda et al., 2007). This is a particularly interesting finding since it suggests an awareness that the water is indeed notclean, but only those with fragile immune systems (the young and the ill) are at risk of

becoming ill from drinking it. These are just a few examples of the types of culturalfactors that should be considered when doing preliminary research about the most viablePOU option for a community.


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1%,TMSN+S'*Treating water with chlorine on a municipal level has been practiced since the early 20 th century and is a major contributor to the decline of waterborne diseases in U.S. cities(Kotlarz, Lantagne, Preston, & Jellison, 2009). Chlorine is most effective against bacteriasuch as E. coli and less effective against parasites (Arnold & Colford, 2007).

Point of use treatment of water with chlorine (usually in the liquid form of sodium orcalcium hypochlorite) is quite simple:

Step 1: Add a measured dose of chlorine to untreated water Step 2: Shake or stir the water to ensure adequate distribution Step 3: Let the water sit for a measured amount of time to allow the chlorine to

act before using

Both the chlorine dosage and the length of time the water needs to sit is determined bythe concentration of the chlorine solution, the volume of water being treated, and thelevel of turbidity in the water. The recommended chlorine dosage is often based on 20Lvolumes, the volume of jerry cans that are common in many parts of the world.

In addition to liquid chlorine, chlorinetablets made of sodiumdichloroisocyanurate (NaDCC) under

brand names such as Aquatab, have been used in emergency situations foryears; in the last decade these tablets have been marketed in developing countries as analternative to liquid chlorine to treat water on a household level (Clasen, 2009). Thesetablets dissolve quickly (and visibly, which end-users typically like), and the water can beused within 30 minutes to an hour, depending on the dosage and the amount of water

Turbidity: a measure of the cloudiness of water, oftenused to indicate water quality. High levels of waterturbidity are often associated with higher levels of viruses,

parasites, and some bacteria.-- http://water.epa.gov/drink/contaminants/index.cfm


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used. A 2007 study examining the use of NaDCC tablets in a Bangladesh village foundhigh levels of compliance among the fifty families using the tablets during the study

period (TF Clasen, Saeed, Boisson, Edmondson, & Shipin, 2007). However, there wasnot a follow-up study post-intervention to determine the rate of use among participantsafter the study was completed.

Treating water with chlorine and then storing it in a safe water container is anintervention known as the Safe Water System (SWS). This particular intervention alsoincludes an array of water and food handling health promotion activities and wasengineered in the early 1990s by the U.S. Centers of Disease Control (CDC) and the PanAmerican Health Organization (PAHO) in response to a cholera epidemic in LatinAmerica. The storage containers are covered containers that have taps and narrowopenings in order to reduce the risk of people contaminating the stored water with theirhands. The SWS intervention has been extensively field-tested in over 30 countries since1998, and studies have shown that SWS can reduce diarrheal disease incidence from 26to 84% in a participating community (Kotlarz et al., 2009). However, the extent to which

the same study population continues to regularly and effectively use chlorine to treat theirwater after the intervention study period ends is not clear; studies have suggested that it isa lower number than the one measured during the study period (McLaughlin et al., 2009).

A significant challenge to the chlorination method by either tablet or liquid is the issue oftreating turbid water. Turbid water contains suspended organic particles and often lookscloudy or murky. When water is turbid, chlorine may be ineffective due to chlorinedemand, the consumption of available chlorine by organic matter in the water before it isable to disinfect microbes. This obstacle in treating turbid water can sometimes beovercome by increasing the dosage of chlorine. However, it is often difficult for end-users to accurately gauge how much to increase the chlorine dosage to compensate for theturbidity of the water. Additionally, the distinct taste and smell of chlorine-treated waterhas been found to be a barrier to end-users; unfortunately, when water is turbid, theincreased chlorine and its interaction with the organic materials in the water furtherincreases the unfavorable taste and smell of the water. Furthermore, chlorinating turbidwater may make the water drinkable, but it will not reduce the cloudy, dirty look of thewater, making it difficult at times to convince end-users that the water has been purified(Kotlarz et al., 2009).

2,% S* -*PS"Several studies in India have shown resistance from end-users to using chlorine-treatedwater due to the perceived unpleasant change in taste and smell (Brick et al., 2004; Firthet al., 2010; Gopal et al., 2009). In a Firth et al. study (2010) of different POUinterventions in a rural South Indian village, 83% of the women in the chlorine groupexpressed dissatisfaction with using chlorine due to the smell and taste; only three out ofthe 126 women in the entire intervention expressed a desire to use chlorine to treat theirwater, despite the fact that it was the most successful intervention in the study in reducingthe level of pathogens in the water. In the same study, villagers reported that, after theoverhead government water tanks were treated with bleach powder, they would wait 2-3days to draw water from the tanks in order to allow the chlorine taste to recede from thewater (Firth et al., 2010). This described practice may represent a health hazard, since


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chlorine breaks down over time. After no available chlorine remains in the water, there isan opportunity for any remaining bacteria in the water to re-grow.

Additionally, the narrow openings of the safe water storage holders have been problematic for some areas in southern India. One study indicated that, compared to

North India, the South has more areas with lower water pressure, necessitating that amanual or a motorized pump is used to fill the water containers in a reasonable amount oftime. By using these pumps, the flow of water is often larger than the opening of the safewater storage container, thus spilling over the opening and wasting water. Since water isscarce and treated as a precious resource, wasting it is frowned upon; therefore, waterstorage containers with narrow openings are not as commonly used in South India (Bricket al., 2004).

)',+Chlorine in liquid form is widely available throughout southern India, along witheffervescent NaDCC tablets in varying dosage sizes (Aquatabs is one widely known

brand of tablets). A typical bottle of chlorine concentrate costs around USD $1 and cantreat over 1,000 liters of water. The NaDCC tablets are more expensive and cost aroundUSD $.01 to treat 1 liter of water (Sobsey et al., 2008).

Since chlorine is a consumable good, it needs to be continually purchased. In cases ofeconomic hardship, end-users may choose to not use as much chlorine as needed to treatthe water in order to stretch their supply, which would render the treatment less effectiveto totally ineffective; or, they may choose to forego buying any chlorine at all(McLaughlin et al., 2009).

6PU"*+"V%, Chlorine solution and tablets are readily accessible in India Relatively cheap Effective against a wide array of pathogens if used properly Easy to transport and store Treats the water quickly (less than 1 hour typically) If combined with a safe water storage container, prevents fecal re-contamination

of the water

1S,"PU"*+"V%, The smell and taste of chlorine-treated water is a problem for many end-users The chlorine must be continually purchased The level of turbidity in the water can impact the effectiveness of the chlorine

(e.g., more turbidity means more chlorine must be used; however, turbidity is afactor that is difficult to measure by sight) The safe water storage container specifications may be problematic in parts of

South India (Arnold & Colford, 2007; Clasen, 2009)


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@/2+.% 4( !7% %33%1- *3 " DOM 17$*./,%C3$*11+$",- 0"17%- *, -+.#/8 ;"-%. USD $.01/liter in most

places (Sobsey et al., 2008), making it fairly expensive compared to other POU options.

6PU"*+"V%, An effective treatment for turbid water


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Visibly makes the water clearer which increases the aesthetic nature of the water Powders are pre-measured in the sachets, making it easy to use. The only

measurement required is to make sure end-users do not use more than 10 L ofwater at a time.

The chlorine-flocculant sachet can be easily used in conjunction with a safe water

storage system

1S,"PU"*+"V%, People may still be resistant to using it if the water tastes or smells too strongly of

chlorine; also the treated water can impact the taste and appearance of certainfoods.

One of the most expensive of the POU options reviewed, and, as a consumable,needs to be continually purchased and, thus, may be foregone during times ofeconomic hardship.

End-users need ready access to a supplier Treats a relatively small amounts of water at a time (10 liters)


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@/2+.% 6( ).*00C0%1-/*, *3 " B/*0",8 @/$-."-/*, PF0-%A< 1*+.-%0F *3 )RSP!http://www.cawst.org/en/resources/pubs

1%,TMSN+S'*Slow sand filtration treatment of communal water has been in use for more than acentury. In the early 1990s, a household-level version of the slow sand filter, the biosandfilter (BSF), was introduced by a Canadian researcher with an important design changethat allowed the system to operate with only intermittent water flow, unlike thecontinuous water flow needed with previous slow sand filters (Clasen, 2009; M.A. Elliott,Stauber, Koksal, DiGiano, & Sobsey, 2008). Enthusiasm for the biosand filters by several

NGOs (most notably, Samaritans Purse) has led to it being distributed in over 24developing countries around the globe.

The biosand filter is one of the more technically complex of the reviewed POU treatment

systems. Elliott et al (2008) describe the gravity-fed mechanics of the BSF as follows:

1) Water is poured into a concrete or plastic chamber filled with locally availablesand.

2) The water goes through a diffuser plate (made of either of plastic or metal) thatdistributes the water more uniformly in the sand and prevents disturbing the

biolayer (described in # 4).


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3) There is an outlet pipe that is elevated in order to allow the filter to maintain alayer of water above the surface of the sand.

4) Due to the constant layer of water above the sand, the sand bed remains wet andcauses a biolayer of microorganisms (referred to as the schmutzdecke) to form.The schmutzdecke is one of the key components that removes pathogens in the

filtration process. It may take up to 30 days for the biolayer to become wellestablished; during this interim period, it is recommended that the filtered wateralso be treated with another form of disinfection to ensure that it ismicrobiologically safe (CAWST, 2010).

5) The water filters through the sand and gravel layers and drains to the bottom ofthe container; there it reaches the outlet pipe, which naturally conducts the waterto the outside for collection.

6) Biosand filters need to be cleaned periodically; otherwise, the flow rate will slow.Cleaning BSFs consists of removing the top several centimeters of sand andreplacing the water on top (M.A. Elliott et al., 2008).

The biosand filter can be made out of local materials and the containers are typicallymade of either concrete or plastic. The concrete filters tend to be more durable than the plastic ones. With either type, the amount of sand and gravel needed for the filter meansthis is a heavy product (a concrete version can weigh up to 260 lbs) and can be labor-intensive to produce and install (South Asia Pure Water Initiative, 2011a). Consequently,

biosand filters are usually made relatively close to the areas in which they will be used(Clasen, 2009). Once a BSF is installed, however, there is little to no maintenanceinvolved beyond a periodic scouring of the top part of sand and water. The ease of useand relative lack of maintenance may be one reason that BSFs have one of the highestrates of continued use by consumers in follow-up study surveys (approximately >85%)(Sobsey et al., 2008). In a recent follow-up study of biosand filter use in the Dominican

Republic, 90% of the households involved in the original intervention were found to still be using their biosand filters one year later (Aiken, Stauber, Ortiz, & Sobsey, 2011).

Multiple studies have demonstrated the efficacy of BSFs in reducing water pathogens like E. coli and improving water turbidity, especially as the biolayer grows over time (M.A.Elliott et al., 2008; C E Stauber et al., 2006). In a randomized control trial in theDominican Republic, the incidence rate of diarrheal disease among BSF households wassignificantly lower when compared to non-BSF households, indicating a protective effectof using the BSF system (Christine E Stauber, Ortiz, Loomis, & Sobsey, 2009).

One of the greatest advantages of the BSF system compared to other non-electric POUoptions is that it can produce large volumes of treated water (.25 to 1 liter per minute orten to hundreds of liters per day), which can then be used for household purposes beyonddrinking water (Clasen, 2009; Sobsey et al., 2008). This feature is especially importantfor households with multiple families occupying the same dwelling.

2,% S* -*PS"There are biosand filter production facilities in southern India. One example is the SouthAsia Pure Water Initiative, Inc. (SAPWII), a non-profit organization based in Connecticut


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that has a production facility for BSFs in the Kolar District outside of Bangalore,Karnataka. As of November 2010, they have introduced biosand filters to 14 villages inand around the Kolar District (South Asia Pure Water Initiative, 2011a). Another notablegroup is the DHAN Vayalagam (Tank) Foundation, an Indian-based grassrootsorganization that focuses on developing water resources in resource-poor areas in

southern India. They advocate biosand filters as the POU option of choice for Indianschools and households in rural areas. DHAN leads 3-4 day workshops that teachinterested villagers how to build and install biosand filters along with basic hygiene andsanitation lessons (see Appendix C for an example brochure for this training). Theseworkshops have been taught in Karnataka, Andhra Pradesh and Tamil Nadu states(DHAN Vayalagam Foundation, 2006).

)',+The biosand filtration system has the highest upfront cost of the POU systems examinedin this reportthe cost for a family to buy a biosand filter typically ranges between $25-$100, depending on the country. SAPWII does not list the actual cost of the filters ontheir website, but they acknowledge that they sell the filters for only half of what itactually costs to produce them and that they raise the rest of the funds from donors(usually Rotary Clubs in America) (South Asia Pure Water Initiative, 2011a). The DHANFoundation teaches villagers to make the biosand filters themselves; they also do not lista cost for the filters on their website.

6PU"*+"V%, Produces a greater volume of water than other POU options Easy to use and has very low maintenance requirements after initial installation Makes the water look cleaner by reducing turbidity Does not break easily Once it is installed, no further costs are usually associated with it Has the highest documented post-intervention usage of all the non-electric POU

options Once installed, can be used for years

1S,"PU"*+"V%, Highest upfront costs of the reviewed POU options There is not a safe water storage container built into the design; therefore, the

water is subject to re-contamination if not stored in the proper container.

Dissemination of the BSF system is highly dependent on a production facility being nearby The growth of the biolayer takes time, so the filter is less effective in cleaning the

water in the beginning stages (M.A. Elliott et al., 2008).


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@/2+.% J( R 3/,/07%8 1%."A/1 3/$-%. ",8 1*,-"/,%. ;/-7 " 1.*00C0%1-/*, *3 -7% A%17",/10 *3 " 1%."A/1 3/$-%.

Potters for Peace at http://s189535770.onlinehome.us/pottersforpeace/?page_id=9 1%,TMSN+S'*Using porous fired clay (ceramic) to filter water is a technique that has been used sincethe mid-19 th century; painting colloidal silver on the ceramic to aid in the removal of

bacteria is a more recent development. While various candle ceramic filters (so namedfor their hollow cylindrical shapes) have been produced for years by commercialcompanies around the world, they are typically more costly and marketed to the middleclass (Clasen, 2009). This report focuses on the pot-shaped ceramic filters that have been

promoted by organizations such as Potters for Peace and IDE for use in low-income populations (Fig. 5).

In this design, the ceramic vessel is shaped like a large flowerpot and has sand andsawdust added to the clay. The sawdust burns out during the firing process, increasing the

porosity of the ceramic. After the clay is fired, a colloidal silver solution is painted on both the inside and outside of the pot. The silver acts as an antimicrobial agent and aids inthe elimination of pathogens in the water. The ceramic pot is placed in a larger coveredcontainer (usually plastic) that has a spigot. The process of filtering the water is simple:one pours the water into the top of the pot and waits for it to filter through the ceramicand collect at the bottom of the plastic container (H. M. Murphy, McBean, &Farahbakhsh, 2010). The ceramic filter unit requires a periodic manual cleaning toremove the impurities left by the water; if it is not cleaned regularly, it is less effective;additionally, the flow rate of the ceramic filter appears to decrease over time even with

periodic cleanings (Sobsey et al., 2008).

The effectiveness of the pot-style filter is reduced if the production methods are notstrictly adhered to. Both the porosity of the ceramic and the amount of silver applied tothe pot impacts the efficacy of the filter; therefore, strict quality control measures must be


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maintained during the production process in order to maintain high filtration andtreatment standards (Clasen, 2009).

When used properly, several studies have shown ceramic filters to be effective inremoving pathogens such as E. coli , and reducing diarrheal disease by as much as 40-

70% in households that use them (J. Brown, Proum, & Sobsey, 2009; T. F. Clasen et al.,2004; Thomas F. Clasen, Brown, & Collin, 2006).

2,% S* -*PS"While commercial ceramic candle filters have been sold in India for several decadesand appear to have a high level of acceptance among the population, less is known aboutthe dissemination of the flower-pot styled filters. In 1996, an estimated 15-25% of middleto upper income Indian households around Delhi, Kolkata, Mumbai, and Chennai wereusing ceramic filters (Anderson, 1999). The acceptance of ceramic candle filters in themiddle to upper income population in India may lend the pot-style ceramic filters anaspirational aura and thus make villagers more willing to use them. A 2005 Potters forPeace activity report stated that IDE and the Practica Foundation (both advocates ofceramic filters), consulted with a small ceramic filter production facility outside ofBangalore in Karnataka state. The same report also notes that Potters for Peacethemselves sold a small number of filters to an NGO in South India (Potters for Peace,2005). Despite these indicators that ceramic filters are being produced (and possiblyused) in southern India, published reports on the dissemination of flower-pot shapedceramic filters in India were not found.

)',+The estimated cost of a pot-styled ceramic filter and its plastic water container isapproximately USD $8-10 depending on the country. Replacing the filter unit costsaround $4-5 (Sobsey et al., 2008).

6PU"*+"V%, Easy to use Can filter turbid water and make it look clearer One filter can be used for 2-3 years if maintained properly The Potters of Peace design incorporates a safe water storage container which

helps prevent re-contamination of the water There is already a high level of acceptance of ceramic filtration among the middle

and upper income Indian population, which may make implementation of pot-

style filters in villages easier because they may be viewed as more of a high-class item

1S,"PU"*+"V%, Fragile construction (i.e., the ceramic can break) If broken, need ready access to replacement parts which may not be feasible for

people in rural areas


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Filter requires regular cleaning in order to maintain effectiveness and flow rate Produces a lower volume of treated water, due to the low flow rate of 1-3 liters

per hour, depending on the turbidity of the water Flow rate may decrease over time, even with regular cleanings


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1%,TMSN+S'*Interest in using solar energy (ultraviolet radiation + infrared heat) to treat unclean water

began in the mid 1980s. This method of water treatment has four main steps:

Step 1: Collect clear, plastic polyethylene terephthalate (PET) bottles that areapproximately 1-2 liter in size (e.g., empty Coca-Cola bottles).

Step 2: Clean the bottles. Step 3: Fill the bottles with untreated water and shake them to aerate the water. Step 4: Close the bottles and place them horizontally to full sun exposure for at

least 6 hours. The amount of sun exposure time needed to effectively treat thewater depends on multiple factors: bottle size, cloud coverage, latitude, altitude,season, and the turbidity of the water are the main factors to take intoconsideration when determining the treatment time. If the weather is rainy orcloudy, it is recommended that the bottles be left out for 1-2 days in order toensure that the water has been exposed to ample sunlight (Swiss Federal Institutefor Environmental Science and Technology/Department of Water and Sanitationin Developing countries (EAWAG/SANDEC), 2002).

Typically, the bottles are stored on rooftops or on the ground during the treatment process. If there is a large amount of turbidity in the water it can affect the UV radiation;as a result, highly turbid water should undergo a filtration process of some kind beforeusing the SODIS method. The amount of treated water produced using SODIS dependson the number and size of bottles a family has (example: 5 liter bottles = 5 liters oftreated water after sun exposure).

Several studies have documented the effectiveness of SODIS in reducing the incidence ofdiarrheal disease in communities. In two studies in India, the estimated diarrheal


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incidence rate among children was reduced anywhere from 40 to 75% when the familytreated their water with the SODIS method (Rai, Pal, Kar, & Tsering, 2010; Rose et al.,2006). One of the major challenges with SODIS is that study participants use of themethod usually declines (sometimes dramatically) after the study period ends. In afollow-up assessment of households that took part in a SODIS program in Nepal,

researchers found that only 9% of study participants had decided to keep using theSODIS method to treat their water in the three months since the program had ended. Themain complaints from the villagers were that the SODIS method took too much time andthat the water smelled and tasted bad, complaints that have been cited by participants inother studies as well (Rainey & Harding, 2005).

2,% S* -*PS"A SODIS project was created in the southern state of Tamil Nadu in 2002 in partnershipwith the League of Education and Development (LEAD). An estimated 275,000 familiesuse the SODIS method in all of India, with approximately 100,000 of those in Tamil

Nadu (Swiss Federal Institute for Environmental Science and Technology/Department ofWater and Sanitation in Developing countries (EAWAG/SANDEC), 2010).

)',+PET bottles are widely available in the developing world and can be purchased at low-cost. Bottles need to be replaced once they become worn over time. In a cost analysis ofdifferent POU options, the annual estimated cost of using SODIS to treat the waterneeded for an individual for a year (including training costs to teach people the correctmethod) is USD $0.63 (Clasen et al., 2007).

6PU"*+"V%, Uses materials that many people already have on hand (empty soda bottles, roof,

the sun) The only non-commercial of the POU options Parts (i.e., soda bottles) are typically easy to replace

1S,"PU"*+"V%, Effectively using the SODIS method can be difficult due to the multiple variables

that impact the length of time the water needs to be exposed to sunlight. It can beespecially difficult for end-users to determine if the water is too turbid and needs

to be filtered before using the SODIS method (Sobsey et al., 2008). Does not necessarily improve the look, taste or smell of the water Produces a relatively small amount of water: the amount of water treated is

limited to the number of bottles a family owns Lack of space for the bottles during treatment phase has been cited as a problem

(Rainey & Harding, 2005) Can take a long time to treat the water (6 hours to 2 days), so people must plan

ahead for their drinking water needs


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1%,TMSN+S'*Boiling water is one of the oldest and most common household methods used in thedeveloping world to treat water. WHO notes that more than 90% of the population incertain Asian countries use boiling as the preferred method to treat their water (Clasen,2009). When used properly, boiling is also one of the most effective ways to disinfectwater. Although the boiling point of water at sea level is typically 212 o Fahrenheit or100o Celsius (depending on impurities in the water, which can affect the boilingtemperature), studies have noted a reduction of bacteria and parasites even when waterhas been heated to only 70 o Celsius (Clasen, 2009, p. 15). While suggestions vary on thelength of time the water should be boiled, the WHOs Guidelines for Drinking Water Quality states that the water should simply reach a rolling boil (WHO 2004).

2,% S* -*PS"According to a 2005-2006 Indian Demographic and Health Survey, approximately 10.6%of the Indian population said they boiled their water on a regular basis (InternationalInstitute for Population Sciences (IIPS) and Macro International, 2007).

)',+A recent study in rural India suggests that boiling may be an economical way of watertreatment for villagers who have adequate access to natural gas, with an estimated cost of

US $0.88 per month for the gas needed to boil 6 liters of water per family per day (Firthet al., 2010). Another study estimated the annual cost of boiling water for a household inIndia at US $2.11 for those using petroleum gas and US $1.66 for those using wood(Thomas Clasen et al., 2008).

6PU"*+"V%, Many people are already familiar with the concept of boiling to treat water


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ID

Needed hardware (e.g. heat source and pot) already in place in most homes Effectively kills most pathogens if water is boiled

1S,"PU"*+"V%, Does not remove chemicals (like arsenic) or turbidity from the water or

necessarily improve taste Does not incorporate a safe water storage system component, thus one must be

added in order to avoid re-contamination of the water Takes time to bring water to a boil and then let it cool to drinking temperature Not usually able to produce large quantities of water for a family May be cost-prohibitive for low-income families Can be labor and time-intensive to collect wood, biomass, charcoal, etc., most of

which typically falls upon women and children. The time taken to gather suppliesand boil the water may detract from schooling or other productive activities.

If using wood, contributes to deforestation Depending on how and where the water is boiled, may increase danger of other

health hazards such as skin burns and indoor air pollution (Clasen, 2009)

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A major part of planning any POU health intervention program is to conduct a literaturereview of existing research. The CDCs Safe Water System Handbook (1999) provides aframework of topics to consider including in the literature review before beginning awater or sanitation intervention in a community (for the complete list, see Appendix B):

Epidemiological data: What types of diseases occur in the village? Who gets thediseases?

Water infrastructure: How are people getting water? What is themicrobiological quality of the water at the source of collection?

Water handling practices: Is storing water common? In what types of containersare people storing their water?

Socio-cultural aspects: What cultural barriers may exist to a POU intervention?What do they believe about the causes of diarrhea? What are their beliefs aboutwater? Who traditionally controls money in the family (important if the POUintervention will cost money)?

Economic aspects: Can the community pay for the POU intervention? If not, are

there donors who are willing to fund a portion of or the entire project? Other possible support and infrastructure: Are there government orcommunity leaders that can be approached for support? Are other NGOsinvolved? (Centersfor Disease Control,1999)

In addition to thecategories listed above, it ishelpful to gather basicdescriptive informationabout an area, such aslocation, primaryindustries, climate, etc.

The literature review willlikely provide informationthat is broadly applicableto the region where thecommunity is located. Togather more community-specific information, theresearcher may use

personal observations,distribute a village survey,or even conduct focusgroups/individualinterviews with thevillagers. Using personalobservation and informal

@/2+.% E( X": *3 U,8/"? X": 1*+.-%0F *3( 7--:(55;;;?A":0*3/,8/"?1*A


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interviewing, the author compiled the following information about Village X in AndhraPradesh:

='T"+S'*

The state of Andhra Pradesh is the fifth largest in India, both in population (74 million)and physical size. The village observed (Village X) is in the Nellore District of AndhraPradesh and is approximately 20 minutes by car outside of Kavali, one of the largesttowns in the district. Nellore District is approximately 4 hours north of the large coastalcity of Chennai (formerly known as Madras) in Tamil Nadu. Nellore District is 13,076sq. km and has direct access to the east coast of India. The Bay of Bengal is 8 km fromthe town of Kavali; Village X is approximately the same distance from the coast.

="*VL"V%The official language of Andhra Pradesh is Telugu.

7T'*'QRApproximately 70% of the population in Andhra Pradesh works in agriculture. Rice,sugarcane, tobacco, bananas, cotton and millet are some of the most common cropsgrown. In Nellore district dairy milk, sugar, rice, stone polishing, fishing and a Nippon

battery factory (an Indo-Japanese alliance) serve as the major industries. While there isnot a national survey that collects data on income in India, a 2008 study that included avillage in southern coastal Andhra Pradesh put the annual per capita median income at7,465 rupees (USD $152) and the annual per capita mean income at 14,341 rupees (USD$292) (Rawal, Swaminathan, & Sekhar Dhar, 2008). These figures are far below thenational per capita income of $1,340, suggesting that this is an impoverished area (WorldBank, 2011). For comparison, thirty Aquatab hypochlorite tablets used to treat water costapproximately 15 rupees; the cost of a Bajaj ceramic candle water filter soldcommercially is approximately 1,200 rupees (Jain, 2009).

)$SQ"+%The patterns of the yearly monsoon season (late June to October/November) stronglydetermine the climate in the state. Temperatures vary from a low of 13 O C in the winter to42O C in the summer months. It is typically humid (WhereInCity India Information,2011).

?S$$"V% C'U%M*Q%*+Indias form of government is a parliamentary democracy. The term, panchayati raj,refers to India's governing system at a local levelit is based on democratically elected

local councils known as panchayats, which are elected every five years. The 73rdamendment to India's constitution (instituted in 1993) reserves one-third of all panchayatseats for women (The Hunger Project, 2011).

6U"S$"#$%


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and a government hospital in Kavali; both charge little to no cost for medical care forlow-income people (defined as those who have white cards, indicating that they makeless than 15,000 rupees annually) (Former Village X Resident, 2011). The consensusamong the locals interviewed is that people have a low opinion of the governmenthospital and prefer the private hospitals if they have a serious illness and can afford to go;

however, comments made by the RMP and the Village X Resident indicated that seekingcare from the private hospital poses a financial hardship for many people in Village X(Former Village X Resident, 2011; RMP, 2011).

Village Health Workers:There is a primary Registered Medical Practitioner (RMP) who practices in a village nearVillage X. Village X is a smaller community and does not have its own RMP, so thevillagers will often see RMPs from other villages. RMPs are similar to village healthworkers and may or may not have formal health training. The RMP the authorinterviewed sees men, women, and children for a wide range of ailments (similar to ageneral practitioner). However, he does not treat pregnant women; instead a local woman

(similar to a village midwife) works exclusively with that population. If the illnessappears serious (such as malaria), he encourages the patient to go to the main governmenthospital in Kavali, approximately 20 minutes away by car. The RMP earns money byselling medicine to his patients.

In 2004, a law was passed in Andhra Pradesh requiring all new RMPs to undergo a yearof government-sponsored health training and then pass an exam in order to receive theirRMP certificate and practice in a local village. For RMPS already in practice, they haveuntil 2014 to take the required government exam needed to maintain their official RMPstatus. The RMP the author interviewed has not received health training and is waitinguntil 2014 to take the exam needed to maintain his RMP certification (RMP, 2011).During the course of the authors conversation with the RMP, there were severalinstances where his understanding of the relationship between water, sanitation anddisease appeared to be lacking. For instance, he did not identify a lack of hand washing,contamination of stored water, or open defecation as potential causes of the yearlytyphoid outbreaks or the common childhood diarrheal disease experienced in the village.Therefore, he is a good candidate for further health training. In general, people whooccupy the position of village health worker (like the RMP) are in a natural position to

promote water treatment and safe sanitation practices in a community; thus, it isadvisable to include them in a POU water intervention program after ascertaining thatthey are indeed respected in the community and are adequately trained.

1S,%",% 9"++%M*, S* +O% )'QQL*S+R Everybody in their lifetime will get one time, typhoid. It is a common thing. We dontworry about it because there is good medicine [for it]. Former Village X Resident

The goal of gathering epidemiological data about disease patterns in a population is togain a broad perspective of a communitys health. Official epidemiological informationfrom an organization that tracks the communitys health statistics (such as a governmentagency or a local hospital or clinic) is ideal. However, if that information is unavailable


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or difficult to locate, examining statewide data about waterborne diseases can be just asuseful.

For example, a 2007 government report lists the following figures for reported incidencesin Andhra Pradesh of three diseases that the government identifies as waterborne:

Diarrheal disease: 1,215,659 cases with 124 deaths Viral Hepatitis: 17,846 cases with 28 deaths Typhoid: 135,550 cases with 12 deaths

(Planning Commission, Government of India, 2007)

These numbers are based on data that is reported by each state to the Ministry of Health& Family Welfare; unfortunately, the report did not outline the reporting mechanismseach state uses to gather these numbers. It is feasible to believe that, since many cases ofdiarrheal disease are often treated at home (especially in more rural areas), the actualincidence rate of diarrhea is higher than the one reported in official government statistics.

In lieu of official epidemiological data, doing a village-wide survey about commondisease complaints can be useful. However, it is quite an undertaking to design andadminister a culturally appropriate survey, let alone to then properly analyze it. Anotherway to gather information is to conduct an informal ethnography of the villagewalkaround, observe people and structures, and talk with the villagers themselves to learnmore about their culture, beliefs, and health issues. Spending time with the health

professionals that treat the villagers can be quite useful as well.

In the authors conversations with various Indian health professionals in Nellore District,several health issues were mentioned that could be linked to unclean water and sanitationand hygiene practices. On the village level, it does not seem that rural villagers are fullyaware of the relationship between health and water and hygiene and sanitation practices.The doctors interviewed in Nellore acknowledged the importance of clean water andgood hygiene and sanitation practices, probably because these doctors were all highlyeducated. During a dinner conversation with an internist, a physiotherapist, and ahomeopathic doctor (trained in the German tradition of homeopathy), they reported themost common issues they see in their patients from the outlying villages:

Gastritisattributed to stress and tension Worms and other parasitic infectionsattributed to a lack of sanitary conditions Anemiaattributed to worm infections Skin diseasesattributed to general unhygienic conditions and worms

The physiotherapist grew up in a rural village outside of Nellore and still returns to hishome village to visit family. He stressed the poor sanitation practices in his home villageand its impact on the villagers health in the form of intestinal worms:

In villages there is no lavatories, they will go outside only. That will infect one person to another person [with worms]. They dont use soap or water to wash


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properly. . . because they dont always have [access to] water. Lack of improperhygiene . . . That is main problem in villages, up to 50% of people there haveworm infection because of lack of sanitary conditions (Three Doctors, 2011).

His assessment of the low rate of hand washing is corroborated by other studies on

sanitation and hygiene in southern India (Banda et al., 2007; Firth et al., 2010). In a studyin northern India about hand washing behaviors after contact with fecal matter,researchers found that approximately 73% of the families observed did not routinelywash their hands after potential fecal contact (Biran et al., 2008). Upon being askedwhere the people in his home village obtain their water, the physiotherapist reported thatthey obtain their water from a bore well. He remarked that the well water is clean, in hisopinion; however, it becomes dirty during storage because of a lack of education amongthe villagers about sanitation (Three Doctors, 2011). While the author was unable toverify if the water from this doctors home village bore well was indeedmicrobiologically pure, the doctors assessment that the water is contaminated during thestorage phase due to sanitation practices is supported by multiple studies in the literature

(Brick et al., 2004; Eshcol, Mahapatra, & Keshapagu, 2009; Firth et al., 2010).In a conversation with Village Xs main care provider, the Registered MedicalPractitioner (RMP), he listed the most common diseases he sees in Village X:

In children: diarrhea and pneumonia In women: problems associated with menstruation, arthritis, anemia and

hypertension In men: hernias and arthritis In everyone: skin diseases

When asked what he thinks causes diarrhea among the children, the RMP asserted that he believes contaminated water causes diarrhea. When asked how the water becomescontaminated, he reported that there is a crack in the pipe that brings water from the borewell to the village government water tank; if the water stays for too long in the watertank, dirt comes in through the cracked pipe and contaminates the water. He did notmention the water being contaminated by the people themselves after collection; nor didhe mention the potential impact of sanitation and hygiene practices such as unsafe waterstorage or open defecation. His comment about contaminated water tanks is substantiated

by some studies which have documented contaminated water coming from poorlymaintained government water storage tanks in India, sometimes with deadly results, suchas cholera and typhoid outbreaks (Anand & Ramakrishnan, 2010; Ramakrishna et al.,1996).

Interestingly, the RMP did not initially identify typhoid as a problem until later in theconversation when he mentioned that a typhoid outbreak occurs on a yearly basis in thevillage when the water changes during monsoon season (RMP, 2011). It appears thatthe RMP and the villagers in general feel that the water quality is poorer during the heavyrains of the monsoon season. This may be true as there is evidence that, if people practiceopen defecation, the rains of the monsoon season may flood the villages and its water


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sources with feces-contaminated water from the outlying fields. According to the RMP,the villagers identify the water changing, mosquitoes, and the flu as all being able tocause typhoid. When asked if the villagers know how to prevent typhoid, the RMPresponded:

They dont know what to do in that situation. But whoever come to us [from thegovernment] they will tell them, take these preventions: like, uhmm, boil thewater, and drink and . . . clean your body well and wash your hands before youeatthings like that (RMP, 2011).

It is worthy to note that the RMP did not appear to believe that the villagers listened tothe advice of the government health officials, indicating that they may not believe thegovernments judgment about the causes of typhoid. This example illustrates the

principle that, in order to devise an effective and appropriate POU intervention, it isessential to elucidate a communitys underlying beliefs about the causes of illness, asthey may be very different from the Western biomedical model.

The author was unable to ask direct questions about defecation practices in the village, asit was not considered appropriate for a foreigner to ask questions of that nature withinthat particular context. However, the RMPs comment that typhoid occurred when thewater changed during monsoon season calls to mind a 2009 spatial mapping study insouthern India that documented the close proximity of the villagers defecation fields towater sources and cultivated fields. The researchers found that the villagers practice ofopen defecation increased the risk of the village and its water sources being inundatedwith fecal-contaminated water during monsoon season, thus increasing the risk of seriousdisease outbreaks (Gopal et al., 2009). Therefore, Village Xs assessment of their waterquality changing during monsoon season may have credence if their water sources are

being contaminated by feces-laden water from nearby fields.

In response to a question about the villagers treating their water, the RMP said that thegovernment provides instructions on boiling water before drinking it; however, he did not

believe that people practiced this method on a regular basis. During the authors time inIndia, boiling was the only non-electric water treatment method mentioned by the various

people interviewed. The more affluent Indians had elaborate electric water treatmentsystems in their homes, such as the reverse osmosis treatment system; however, thiswould be a difficult proposition for Village X because it has only 8-10 hours ofintermittent current a day and the price of the electric water treatment systems is beyondthe reach of the typical village household.


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The houses in Village X are fairly closetogether, and the average walking distance to

a water source appears to be no more than 3-5minutes (and for many it is under 2 minutes).Based on observation, it appears that theresidents in Village X primarily obtain theirwater from deep bore wells that tap into thegroundwater contained in undergroundaquifers. Walking around the village, theauthor observed a variety of wells and hand

pumps that seem to be government installed

(the villagers could not identify anyorganizations besides the government thathelped them with water matters). Some of the

wells could be considered unprotected andunimproved water sources because they areuncovered and require a rope and bucket toaccess the water (Fig. 9). On the other end ofthe continuum, there were a variety ofimproved water sources, such as protectedwater taps (Fig. 10) that likely access waterfrom the bore well through subterranean pipes;this closed system provides a level of protectionfrom contamination, provided that the pipes arenot cracked. There is also a large governmenttank that stores water brought up from a borewell (Fig. 11). It has been noted that the

governments most common method of treating water in rural southern India ischlorination through adding bleaching powder tothe water tanks, such as the one pictured inFigure 11 (Gopal et al., 2009). The author wasunable to verify if the government treated thewater in the water tank on a regular basis.However, several studies that tested water fromgovernment water tanks documented high levelsof fecal contamination at the source ofcollection, possibly due to inadequate levels ofchlorine in the tanks (Firth et al., 2010; Gopal etal., 2009). Additionally, in both a typhoidoutbreak in Rajasthan state and a choleraoutbreak in Tamil Nadu, the primary risk factoridentified among the cases was drinking waterfrom the government water tanks, mainly due to

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the fact that, unbeknownst to the public, the government had stopped treating the waterdue to financial constraints (Anand & Ramakrishnan, 2010; Ramakrishna et al., 1996).Therefore, even if the water in government tank is supposed to be treated on a regular

basis, there is still a chance that it may be microbiologically impure.


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As shown in Figures 10 &11, residents in Village Xuse wide-mouth vessels made of a variety of

materials to collect their water. These types of waterstorage containers are considered unsafe becausehands can be put through the wide-mouth opening,greatly increasing the risk of contaminating the storedwater (Banda et al., 2007; Eshcol et al., 2009). In ahome the author visited, three families live together(referred to as a joint family home) in a house withapproximately five rooms. The dwelling also has alarge, walled courtyard area where the family sleepsin the summertime, works, eats, and stores their

water. After collecting water from the nearby well (< 1 minute walking distance from thehouse), the family empties the containers into a large,uncovered concrete water storage container that has awaterspout on the side (Fig. 12). They then access thewater from either the side spout or by dipping a cup intothe top of the container, again increasing the chance ofcontamination by hands (Brick et al., 2004). Figure 12shows the water storage container for people in thecourtyard; directly across from this water container is asimilar one that is lower to the ground and is used for thelivestock (Fig. 13). From the authors observations, itappears that this is how people in the village typicallystore their water if they do not keep it in the originalcontainers used for water collection. The water storage

practices in Village X are not uncommon and, indeed,confirm what other studies have documented: widespreaduse of open or wide-mouthed storage containers, along with accessing the water bydipping a cup into the top of the container (Brick et al., 2004; Eshcol et al., 2009; Gopalet al., 2009; Sharma, Ramakrishnan, Hutin, Manickam, & Gupte, 2009).

As mentioned earlier, typhoid outbreaks occur on a yearly basis in this village. In a studyof typhoid outbreaks in West Bengal, researchers found that using wide-mouth waterstorage containers and retrieving water out of the containers with a cup were significantlyassociated with typhoid cases (Sharma et al., 2009). Therefore, a POU intervention forthis community should include finding acceptable alternatives to the villages currentwater storage practices in order to reduce the chance of re-contaminating the water duringstorage.

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The joint family home the author visited had aworking latrine that appeared to be in good

condition. However, as previous studies in ruralsouthern India have shown, even with afunctioning latrine at home, it is highly likely thatthe villagers practice open defecation as wellwhich can contribute to diarrheal disease (Bandaet al., 2007). Another Village X practice observed

by the author were people keeping close quarterswith their livestock (including allowing them intothe home), a practice that has negative healthimplications. In a study in rural Bangladesh,researchers found that allowing livestock into theliving area was a significant risk factor in youngchildren developing diarrhea (Pathela et al.,2006).During the evening, the animals are tied to sticks directly outside the walls of the house.

There the animals will defecate, which thencollects into something similar to a sewageditch. Usually a bridge to the entrance ofthe house is made out of a piece of wood orconcrete and placed over the ditch so peoplecan enter the courtyard without stepping inanimal waste (see background in Fig. 14).When animals enter the dwelling, there is thechance that they may have first walkedthrough the sewage ditch before entering thehouse (Figures 14 & 15), thus tracking fecalmatter into the living area where children

play, and people eat their meals and sleep.Clearly, keeping livestock tethered close to homeand sharing living space with them increases therisk of contaminating food and water with animalwaste. For example, an E. coli outbreak in

Scotland in 1999 was traced to fecal contamination of an unprotected water source in anarea where sheep were allowed to roam freely (Licence, Oates, Synge, & Reid, 2001).The practice of keeping ones animals close to home has been noted in another studyconducted in southern India, along with the problems posed by the fecal matter dispersed

by the animals around the dwelling (Gopal et al., 2009). When heavy rains come,uncovered animal and human waste in the fields and around the home can easilycontaminate open wells and lead to disease outbreaks. Therefore, exploring alternativeways to house livestock and deal with animal waste should be considered for Village X.

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='T"$ K%$S%(, "#'L+ 1S,%",% In the authors conversations with the RMP and other locals about illnesses and theircauses, several themes emerged:

Diarrhea was identified as a common problem among Village X children. Both

the RMP and the former Village X resident identified the cause of diarrhea asdirty water. According to them, the water became contaminated in one of threeways: 1) if the water stays in the government tank too long (Fig. 11), it can

become contaminated; 2) the pipe that carries the water into the government tankis cracked, allowing dirt to get into the water; an

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